Office of Clinical Standards and Quality /Survey & Certification Group

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop C2-21-16 Baltimore, Maryland 21244-1850

Office of Clinical Standards and Quality/Survey & Certification Group

DATE:

December 2, 2011

Ref: S&C: 12-06- Hospitals/CAHs

TO:

State Survey Agency Directors

FROM:

Director Survey and Certification Group

SUBJECT: Instructions for Completing Exhibit 286, Hospital/Critical Access Hospital (CAH) Database Worksheet

Memorandum Summary

? Revised Exhibit 286: The Hospital/CAH Database Worksheet, Exhibit 286 in the State

Operations Manual (SOM), has been updated. Instructions for completion have been added to the SOM exhibit.

? Automated Survey Processing Environment (ASPEN) Version of the Worksheet: The

Hospital/CAH Database Worksheet in ASPEN system has been updated to correspond to the latest version of SOM Exhibit 286.

? Completion of Worksheet: Requirements for the completion of the Hospital/CAH Database

Worksheet as part of a certification/recertification kit remain unchanged.

Exhibit 286, the Hospital/CAH Database Worksheet, has been updated to add or refine some fields. Instructions for completing the Worksheet have also been updated, and have been added to the SOM. The ASPEN system has also been updated to correspond to the revised Worksheet.

At this time, the Centers for Medicare & Medicaid Services (CMS) does not require hospitals and CAHs to complete the Worksheet at periodic intervals and submit it to a State Survey Agency (SA) or CMS. In the case of initial certifications of a deemed hospital or CAH, the SA and CMS Regional Office (RO) will follow their current practice for obtaining the needed information from the hospital or CAH to complete the initial certification kit. For currently participating hospitals and CAHs we are continuing the policy that the Worksheet must be completed by the SA for every full survey it conducts of a hospital or CAH. Given that most hospitals and a significant number of CAHs are deemed, and that SAs conduct full surveys of deemed facilities infrequently, we acknowledge that the data base Worksheet information in ASPEN may not be up-to-date. We also acknowledge that some SAs, through their State authority, require all hospitals and CAHs to submit updated Worksheets periodically, and incorporate the information obtained in this manner into ASPEN. We appreciate this assistance by the SAs.

Page 2 - State Survey Agency Directors

Note that the Worksheet and instructions indicate mandatory fields that must be completed in order for the associated certification kit to upload to the national data base. It is crucial, therefore, that these fields are completed for every standard survey of a hospital or CAH conducted by a SA and that the data is uploaded. However, we also stress the importance of completing the Worksheet as fully and accurately as possible, going beyond the mandatory fields whenever possible. Data from this Worksheet is routinely requested in order to update information in Hospital Compare concerning availability of emergency services, as well as to support analysis related to various Medicare hospitals or CAH policies.

Questions about the hard copy of the Worksheet should be addressed to Dina Lansey at Dina.George-Lansey@cms.. Questions about the ASPEN version of the Worksheet should be addressed to Barbara Keller at Barbara.Keller@cms..

Effective Date: Immediately. Please ensure that all appropriate staff are fully informed within 30 days of the date of this memorandum.

Training: The information contained in this letter should be shared with all survey and certification staff, their managers, and the State/RO training coordinators.

/s/ Thomas E. Hamilton

Attachment

cc: Survey and Certification Regional Office Management

CMS Manual System

Pub. 100-07 State Operations

Provider Certification

Transmittal

(Advance Copy)

Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS)

Date:

SUBJECT: Revised Exhibit 286, Hospital/CAH Database Worksheet

I. SUMMARY OF CHANGES: Exhibit 286 has been updated, and instructions for completing this worksheet have been added.

NEW/REVISED MATERIAL -

EFFECTIVE DATE*: Upon Issuance IMPLEMENTATION DATE: Upon Issuance

The revision date and transmittal number apply to the red italicized material only. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual not updated.) (R = REVISED, N = NEW, D = DELETED) ? (Only One Per Row.)

R/N/D CHAPTER/SECTION/SUBSECTION/TITLE

R

Exhibit 286, Hospital/CAH Database Worksheet

III. FUNDING: No additional funding will be provided by CMS; contractor activities are to be carried out within their FY 20xx operating budgets.

IV. ATTACHMENTS:

Business Requir ements X Manual Instr uction

Confidential Requir ements One-Time Notification Recur r ing Update Notification

EXHIBIT 286

(Rev.)

HOSPITAL/CAH DATABASE WORKSHEET

Worksheet completed by the SA surveyor to gather data of worksheet, not to be given to provider to fill out.

CMS Certification Number (CCN): ________________ Date of Worksheet Update: __________

Medicaid Provider Number: ___________________

(MMDDYYYY) (M1)

National Provider Identification Number(s) (NPI): ___________________________

Fiscal Year Ending Date (MMDD): _____________

Name and Address of Facility (Include City, State):

_______________________________________________________________________________

_______________________________________________________________________________

_________________________________________________Zip Code: _____________________

Telephone Number (M2): _________________ Fax Number (M3): ______________________

CEO Telephone Number: ___________________

Email Address: ________________________

Website Address: ______________________

*Accreditation Status:_____ Select one 0 Not Accredited 1 JC 2 AOA 3 DNV

*Effective Date of Accreditation: __________________ (MMDDYYYY) (M4)

*Renewal Date of Accreditation:____________________ (MMDDYYYY) (M5)

*Multiple Accreditation Status: Yes

No

(Select all others that apply; do not include the accreditation organization listed above):

JC

AOA/HFAP

DNV

State/County Code (M6):__________

State Region Code (M7):__________

* - Mandatory field, must be entered for survey kit to upload

*Type of Program Participation (M8):_____ Select one 1 Medicare 2 Medicaid 3 Medicare & Medicaid

CLIA ID Numbers (M9):

________________________________ ________________________________ ________________________________

Medicare CAH Status or Type of Medicare Hospital (select one) (M10):___________

01 Short-term ___

06 Childrens___

02 Long-term ___

07 Distinct Part Psychiatric Hospital__

03 Religious Nonmedical Health Care Institution___

04 Psychiatric ___

11 Critical Access Hospital (CAH)___

05 Rehabilitation ___

* Affiliation with a Medical School

(M11):_____

01 Major

02 Limited

03 Graduate School

04 No Affiliation

* Resident Programs (M12) (select all that apply):____________________________

01 Allopathic 02 Dental 03 Osteopathic

05 Podiatric 09 Other

*Ownership Type (select 1) (M13):______

01 Church

06 State

02 Private (Not for Profit)

07 Local

03 Other 08 Hospital District or Authority

04 Private (For Profit)

09 Physician Ownership

05 Federal_

10 Tribal

Average Daily Census (M14):______

Number of Staffed Beds (M15):_______

* - Mandatory field, must be entered for survey kit to upload

*Type of Chain/Health System Involvement (M16):______

01 None 02 Joint Venture/Partnership 03 Operated/Related 04 Managed/Related

05 Wholly Owned 06 Leased 07 Other

Name of System (M17):______________________________________________________________

Corporate Headquarters City (M18):_________________________________ State (M19):______

*Number of state-licensed beds: ______ *Number of operating rooms: _______ *Number of endoscopy procedure rooms: _______ *Number of cardiac catherization procedure rooms: _____

Separately Licensed: Yes Separately Licensed: Yes Separately Licensed: Yes

No No No

Number of Employees Salaried by Hospital/CAH

(Use Full Time Equivalents FTE)

M20 Physicians (Salaried only)

M30 Medical Technologists (Lab)

M21 Physicians - Residents

M31 Nuclear Medicine Technicians

M22 Physician Assistants (PA)

M32 Occupational Therapists

M23 Nurses - CRNA

M33 Pharmacists (Registered)

M24 Nurses - Practitioners

M34 Physical Therapists

M25 Nurses - Registered

M35 Psychologists

M26 Nurses ? LPN

M36 Radiology Technicians

(Diagnostic)

M27 Dieticians

M37 Respiratory Therapists

M28 Medical Social Workers

M38 Speech Therapists

M29 Medical Laboratory

M39 All Others

Technicians

* - Mandatory field, must be entered for survey kit to upload

Medicare Payment-Related Categories for a Hospital or a CAH (select all that apply) (M40):_______

CAH Categories

Hospital Categories

01 CAH Psychiatric DPU

07 Hospital PPS Excluded Psych

Unit

02 CAH Rehabilitation DPU

08 Hospital PPS Excluded Rehab

Unit

03 CAH Swing Beds

09 Hospital Swing Beds

10 Medicare Dependent Hospital

11 Regional Referral Center

12 Sole Community Hospital

* - Mandatory field, must be entered for survey kit to upload

*Services Provided by the Facility (M41):______

0 Not Provided 1 Services provided by facility staff only 2 Services provided by arrangement or agreement 3 Services provided through a combination of facility staff and through agreement

02 Alcohol and/or Drug Services 03 Anesthesia Service 04 Audiology 06 Burn Care Unit 07 Cardiac Catheterization Laboratory 08 Cardiac-Thoracic Surgery 09 Chemotherapy Services 10 Chiropractic Service 11 CT Scanner 12 Dental Services 13 Dietetic Service 14 Emergency Department (Dedicated) 16 Extracorporeal Shock Wave Lithotripter 17 Gerontological Specialty Services 20 ICU - Cardiac (non-surgical) 21 ICU - Medical/Surgical 22 ICU - Neonatal 23 ICU - Pediatric 24 ICU - Surgical 26 Laboratory-Clinical 28 Magnetic Resonance Imagining (MRI) 29 Neonatal Nursery 30 Neurosurgical Services 31 Nuclear Medicine Services 32 Obstetric Service 33 Occupational Therapy Services 34 Operating Rooms 35 Ophthalmic Surgery 36 Optometric Services 38 Organ Transplant Services (Not

Medicare-certified) 39 Orthopedic Surgery 40 Outpatient Services 41 Pediatric Services

42 Pharmacy 43 Physical Therapy Services 44 Positron Emission Tomography Scan 45 Post-Operative Recovery Rooms 46 Psychiatric Services - Emergency 47 Psychiatric - Child/Adolescent 48 Psychiatric - Forensic 49 Psychiatric - Geriatric 50 Psychiatric ? Adult Inpatient 51 Psychiatric - Outpatient 52 Radiology Services - Diagnostic 53 Radiology Services - Therapeutic 54 Reconstructive Surgery 55 Respiratory Care Services 56 Rehab Services - Inpatient 58 Rehab -Outpatient 59 Renal Dialysis (Acute Inpatient) 60 Social Services 61 Speech Pathology Services 62 Surgical Services - Inpatient 63 Surgical Services - Outpatient 64 Trauma Center (Designated) 65 Transplant Center (Medicare Certified) 66 Urgent Care Center Services

* - Mandatory field, must be entered for survey kit to upload

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